The First Code

I am physically and emotionally exhausted. It's only week 4 of a 10 week rotation, and I'm dragging my feet, counting down the days, and watching the clock during the day. For me, this is worse than surgery. It's the hours, yes. Most weeks it's 70 hours, and if long call falls on the weekend (which is does for at least 5 weekends out of the 10 weeks) then it's 80 hours of work. It's the patients also, not that I blame them for being so very sick. Heart disease, kidney disease, lung disease, liver disease, blood disease....all the diseases that I have learned about in the last 2 years of lecture and self-study. I try to remind myself that the hours spent at the hospital, and with these sick patients, will help me to become a better doctor. Their suffering and diseases will help me to do better on my next board exam. I try to daily keep up with the vast array of knowledge that I am reminded I do not remember, or have never even learned. Yes, I am trying to see the cup as half full, but the truth is that I am almost completely empty.

I'm still trying to process the first code I have ever seen. Code is synonymous with some one's heart stopping, and the subsequent attempt to resuscitate the patient. It occurred 3 days ago, on our long call night, and the images still flash in my mind, right before I fall asleep at night, right at the time that I am most wanting to shut out the pain from my daytime hours.

I see her listless hand flopping up and down against the sheet, in between the ten or more doctors that surround her bed, as my senior resident does chest compressions. I glimpse her face, stark in the absence of life, and yet her eyes are open. I see one of the doctors intubate her with a breathing tube. I see yet another use a drill to put in IV access into the tibia bone of her lower leg. I hear the shouting of orders from the doctor leading the code. "How much epi has been given?" "Stop compressions! Check for pulse!" "More epi!"

Thankfully she wasn't my patient. I'm not sure that I am ready to loose a patient. She "belonged" to another student, who had seen her just an hour before, and although the patient was sick enough to be in the hospital, she certainly didn't look like some one who's heart was soon to stop. We stood in the hallway, running to get supplies if we could, otherwise feeling completely powerless, not only in our ability to help, but also in our ability to turn away. It was like watching a car accident in process. I couldn't turn away, certain that I would miss something, certain that she would definitely be gone if I walked away.

45 minutes passed. We did get some electrical activity in her heart, from the drugs given, but there wasn't enough to coordinate contractions to get the blood moving into her now floppy limbs. The lead doctor eventually decides it's time to stop. One by one, each of the doctors relinquish their duties. The anesthesiologist takes out her breathing tube. The heart monitor electrodes are peeled off her skin. The IV line that was drilled into her leg is removed. One by one they all leave the room. The nurses stay behind to continue cleaning her up, to prepare her for her family who is on the way. The same family that had just left hours before, with plans on returning in the morning to find out what we had discovered about her disease process. I waited in the hallway until the nurses closed the curtain. I was allowed to watch this heroic and seemingly barbaric attempt to bring her back, and yet was not allowed to be a part of what I hoped was a gentle apology for what we had put her body through. And that's just it. At the point of the attempted resuscitation, it was just her body, so clearly empty of life.

Her family showed up and were taken to the room. Crying could be heard from the hallway. I don't know that I could ever get used to telling someone that their loved one died. How will I keep the tears from my own eyes? We have no idea why she died, so unexpectedly, and will never find out as the family did not agree to an autopsy. We returned to our workroom at midnight, shocked, tired, and still with lots of work to do. We talked about what we could have missed. What signs did she give us that she was this close to death? What lab tests could we have ordered to give us a better sense of her sickness?

If that wasn't enough for one week, we got another very sick patient, dying of liver failure. At least with this patient, it was clear that she was going to die, it was just a matter of when. She lasted about two days in the hospital, as her organs shut down one by one. First her liver went (she was very yellow from jaundice), then her kidneys failed (no more urine production), her heart faltered (blood pressure dropped), and her lungs struggled for the last breaths of her life. We went into the room yesterday morning, to give the dismal prognosis to the family, telling them she was not a candidate for liver transplant, that her organs were shutting down one by one, that it would most likely be hours, and not days, before she passed. The tension and grief in the room was palpable. All of her children were there, as well as both of her parents, as she was a young fifty something year old woman. The only way I could keep my own tears from falling was to pretend to not be in the room. To not be present at all. Will I ever get used to this? And do I even want to? For now, I return home everyday with a heavy heart, and reluctance to get out of bed the next day and do it all over again.

Sick Doctors

I remember once during my massage years seeing one of my regulars who was an ophthalmologist (eye doctor) and asking how he had been since his last massage. He reported that he was very very sick, sicker than he had been in many years. I asked him if he took any time off work, to which he smiled and said "Doctors don't take time off when they are sick," which I figured at the time was just a representation of his generation. He was an older man, near retirement himself after a life of giving up his time to medicine, and had that "old school" mentality where it is expected for doctors to work over 100 hours a week, and work when sick, all without complaint. After just two weeks working in the hospital with internal medicine residents, I've realized that the expectation for doctors to work when they are sick is still very much alive.

Take the intern for example. Last week while giving presentations out in the hallways he would have to take a break to wipe his eyes, and the sweat off his brow. While in the rooms leaning over patients to listen to their hearts, he would tip his head way back, and deeply sniff, so that he didn't drip any of his nasal secretions on the patient. After the heart exam he would quickly go over to the sink, blow his nose, then wash his hands, and return to the work at hand, until his secretions sent him to the sink again. We watched him suffer for many days with his illness, all the while being slammed with the work of an intern (something I am NOT looking forward to). He would be sitting at the computer in the call room, with blood shot eyes from being up all night, and a sweaty brow from his fever, with runny nose and eyes, trying desperately to keep up with the relentless incoming pages from nurses about medications or symptoms of his patients. You see when on overnight call, the intern is not only responsible for the ten patients that we have on our team, but is also responsible for what is called "cross cover" - he is also responsible for all the other internal medicine patients in the hospital (because the other interns are home sleeping). My heart broke for him, and I wish that we could have helped him, but unfortunately medical students don't yet have what it takes to do intern level responsibilities.

If that wasn't enough to believe that this whole working while sick thing in medicine is utterly ridiculous, I have been fortunate enough to experience it myself, so that I can know for SURE, that it's absurd. Last week, just days after the intern's snivels started to abate, I started with the infamous sore throat, that soon led to a dry hacking cough. After several days I just started wearing a mask, because more of my time was spent coughing than not. I drank cough syrup like it was candy, and went though a whole bag of cough drops in one day. Thursday was the worst day, as it was long call day, which meant an overnight shift. Thankfully my resident sent me home to do my work, as she was probably sick of hearing me cough in the workroom. So after examining my patient, I went home to spend hours writing my history and physical exam, assessment and plan, and slept a few hours sitting upright on the couch. I returned for rounds early the next morning at 6 am, and spent the next 4 hours in uncontrolled coughing spasms in the hallways of our medicine ward. My eyes watered, I slugged another few doses of cough syrup, and prayed to at least stop coughing long enough to give my presentation to the attending. 3 hours later, after listening to the other medical students give their presentation, as well as the intern discuss the other patients, I finally got to my 10 minutes of "fame" which of course, was interrupted by racking spasms of coughs.

Now what is most disturbing to me about this whole thing, other than the obvious fact that I did NOT belong in a hospital, around patients much sicker than I, who definitely couldn't afford to get my illness on top of theirs, was the fact that we all pretended it was completely normal for me to be at work while sick. I'm looking into the resident's eyes, telling her between coughs what I think we should do for my patient, and it's like a HUGE elephant in the room, my sickness, that is completely ignored. Oh sure, I know that everyone on my team was aware of my sickness, just like we were all aware (and feeling bad about) the intern's sickness the day before. But no one can say anything about it, because like my massage client/eye surgeon told me years ago, "Doctors work when they are sick."

That is one of just many things in the medical profession that is totally insane, from so many points of view. First, there's the possibility of infecting the patients; then there's the idea that when a doctor is sick, they are probably not thinking very clearly (not to mention when combined with the drugs taken to help control the symptoms);and how about being a part of a profession that takes the oath "first do no harm?" Could one argue that going to work sick is not only harmful to one's self (should be at home healing), but also possibly harming a patient?

These are all things that I have thought a lot about this past weekend, as I laid on the couch, coughing up my lungs. As I coughed like crazy this morning, I thought about calling in sick, as I knew that I really need more time to heal (2 days just isn't enough). But here's the thing: I realized that to miss a day of work means that I have to make up this day, and when would I make this day up? I only have one day off a week anyway, and I certainly don't want to come in on a weekend day to make it up. And I imagine the reason doctors go to work sick is the same - when will they make up the work? If they have a whole day of patients, or several surgeries scheduled, when will there be time to fit all those people in? Sure, maybe you would be lucky enough to have another physician pick up your patients for you, but most likely, they are also overworked and have no immediate openings in their schedule. So imagine that a patient has waited three months for an office visit to see their doctor to follow up on some lab results, and the doctor has to cancel because they are sick, and you have to wait another three months. Wouldn't you rather just listen to him or her cough behind a mask, rather than wait? Most of us would probably admit that we wouldn't want to wait, and alas, that is why doctors go to work sick. While I don't have any patients that wouldn't be taken care of in my absence as a medical student, I certainly don't want to spend any more days in this hospital than I have to. So here I am at work, cough, cough, cough.

Short Coats

I just finished a 12 day stretch of work with no days off, that included three 28 hour shifts, on my internal medicine rotation, a ten week rotation that it the core of all medicine. The concepts reviewed in this rotation are the basic building blocks that hold up all other aspects or specialities in medicine. This rotation takes care of very sick patients who are put in the hospital because there is disease or illness in their internal organs - the heart, lungs, kidneys, gastrointestional tract, or blood, to name just a few. I've had patients with pneumonia, angioedema (swelling of tissues due to leaky blood vessels - in the case of my patient, his throat swelled up), AIDS (and the subsequent fungal infection in his brain), acute kidney failure, heart failure after a myocardial infarction (heart attack), endocarditis (bacterial infection of the heart valves), and blood loss due to a tumor in the stomach. As a medical student we are fortunate to only be responsible for one or two patients at a time, while the resident and intern have to know everything about all ten patients that our team takes care of (which I will have to do in only a year and a half).

Having only one patient to be responsible for at a time allows us ample time to talk to the patient, to practice our history taking and physical exam skills, and most importantly, to review the mechanisms and treatment of the diseases so that we can sound competent when we present our patient at the daily rounds. Rounding compromises walking around the floor to each patient's room, and discussing the "case" out in the hallway. There is a very strict order of how information about a patient is given to the rest of the team, and this is standardized across all medical schools and residency programs in the US. You start with a brief one liner that describes who a patient is, and why they were admitted. For example, "Mr. J is a 50 year old man with longstanding hypertension and coronary artery disease admitted for chest pain." You then go into what's called the HPI - history of present illness, which is a chronological account of how the current illness presented itself, a description of the symptoms, onset, duration, therapies previously tried, and any pertinent information that can help the listeners start to whittle down the potential list of what could be the problem for this patient.

After the HPI, you then launch into any other medical conditions the patient has, and what the status of that disease is, or how it is managed. Then it's onto family history of diseases (for example, it would be important to know with Mr. J that his father had his first heart attack at age 45). Then it's social history, where the person lives, what they do for a living, married, children, etc... plus their habits with tobacco, alcohol, and drugs. Then it's a list of their allergies, and medications.

Then you present what you found on physical exam, what the heart, lungs, abdomen was like, paying appropriate attention to those physical exam findings that will having a bearing on what the person was admitted for (you don't need to know Mr. J had clear tymphanic membranes in his ear, but you definitely need to mention what his heart sounds were like - regular rate and rhythm, and murmurs, rubs, or gallops?). Then it's on to the lab findings, where you list out the chemistries and blood cell counts, all the data that internal medicine doctors rely on to give them clues to what's happening with the internal organs. And if you've gotten an x-ray or a CT scan, you need to talk about the results as well.

After all this information is given, the most important part comes, the part where med students sweat the most. The assessment and plan. The "so what do you think about all this information, and what do you want to do for the patient?" You have to list each problem the patient had, whether in terms of their presenting symptoms (Mr. J's chest pain), or their past medical history (his hypertension), and any physical exam findings (say a heart murmur), and any lab abnormalities (say he has hyperkalemia - that's too much potassium in his blood).

No problem right? Well the first week the attending that we worked under wanted this presentation in 5-7 minutes. To make matters worse, while I am speeding through my presentation trying to decide what information is most crucial and cannot be left out, the attending is looking at the computer, most likely looking at the lab results I am trying to relay to him. By the way, the attendings and residents already know everything about the patient, and don't really need the medical student's presentation to make any decisions about care for the patient. This whole process is for the benefit of the student, which is hard to imagine given that most of the time the residents aren't paying attention, and are clearly just wanting you to hurry up so they can get their work done. At the end of my first presentation, the resident looked at his watch and said, "that was 9 minutes."

The second week was totally different in that the new attending gives us 15 minutes for our presentations, which feels so wonderful to have the time, and she actually listens to everything we say, to the point that we have to comment on every single abnormality, ones that the previous attending just blew off. I can say while the new attending means much more work, I prefer her thorough style because it forces me to look up reasons for any abnormalities, to understand the patient completely. It does of course mean that I have to get to work early, so that I don't make the mistake of not knowing why. As I've said before, I think most of the stress of this third year comes not just from the long hours, but from the constant evaluation that is occurring by the residents and attendings - those that will give you your grade, and have a say in your future. It's like constantly being on guard, hackles up, in preparation not for a discussion between equals, but for interactions that question your knowledge and skill as a doctor. I can't tell if the stress of this comes from the high expectations I have of myself (my inherent perfectionism) or from the unreasonable expectation that doctor's should know it all. All I know is that each day that goes by is one day closer to that MD next to my name, that day when I can no longer hide behind the short coat of a medical student.